Practice

Parameters

Practice Parameters for the Management

of Anal Fissures (Revised)
Prepared by
The Standards Practice Task Force
The American Society of Colon and Rectal Surgeons
Charles Orsay, M.D., Jan Rakinic, M.D., W. Brian Perry, M.D., Neil Hyman, M.D.,
Donald Buie, M.D., Peter Cataldo, M.D., Graham Newstead, M.D., Gary Dunn, M.D.,
Janice Rafferty, M.D., C. Neal Ellis, M.D., Paul Shellito, M.D.,
Sharon Gregorcyk, M.D., Charles Ternent, M.D., John Kilkenny III, M.D.,
Joe Tjandra, M.D., Clifford Ko, M.D., Mark Whiteford, M.D., Richard Nelson, M.D.
The American Society of Colon and Rectal Surgeons is dedicated to assuring high quality patient care by
advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus.
The Standards Committee is composed of Society members who are chosen because they have demonstrated
expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in
defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing
Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not
prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a
specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and
patients who desire information about the management of the conditions addressed by the topics covered in these
guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of
care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment
regarding the propriety of any specific procedure must be made by the physician in light of all of the
circumstances presented by the individual patient.

STATEMENT OF THE PROBLEM

An anal fissure is a crack or tear in the vertical axis
of the squamous lining of the anal canal between the
anal verge and the dentate line. Fissures occur most
often in the posterior midline. Acute fissures are superficial, but may deepen to expose the underlying
internal sphincter. Chronic fissures are associated
with secondary changes, which may include a sentiReprints are not available.
Dis Colon Rectum 2004; 47: 20032007
DOI: 10.1007/s10350-004-0785-7
The American Society of Colon and Rectal Surgeons
Published online: 26 October 2004

nel tag, hypertrophied anal papilla, induration of the

edge of the fissure, and/or relative anal stenosis secondary to spasm or fibrosis of the internal sphincter.
Effort should be made to identify the precipitating
cause of the individual patients fissure (e.g., constipation or diarrhea) and manage it appropriately, otherwise the likelihood of recurrence is high. In a minority of patients, a fissure may be associated with a
systemic disease (e.g., Crohns disease) or may be attributable to another diagnosis (e.g., anal carcinoma,
sexually transmitted disease).
These guidelines address the management of the
typical chronic anal fissure. Articles that did not
specify chronicity of the fissure were not included in

2003

ORSAY ET AL

2004

Levels of Evidence and Grades of Recommendationa

Level
I

Source of Evidence
Meta-analysis of multiple well-designed,
controlled studies; randomized trials with
low false-positive and low false-negative
errors (high power)
At least one well-designed experimental
study; randomized trials with high falsepositive or high false-negative errors or
both (low power)
Well-designed, quasi-experimental studies,
such as nonrandomized, controlled,
single-group, preoperative-postoperative
comparison, cohort, time, or matched
case-control series
Well-designed, nonexperimental studies,
such as comparative and correlational
descriptive and case studies
Case reports and clinical examples

II

III

IV

V
Grade

Grade of recommendation

Evidence of Type I or consistent findings

from multiple studies of Type II, III, or IV
Evidence of Type II, III, or IV and generally
consistent findings
Evidence of Type II, III, or IV but inconsistent
findings
Little or no systematic empirical evidence

B
C
D
a

Adapted from: Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules of evidence and clinical recommendations
on the use of antithrombotic agents. Chest 1992;102(4
Suppl):305S11S. Sacker DL, Rules of evidence and
clinical recommendations on the use of antithrombotic
agents. Chest 1989;92(2 Suppl):2S4S.

this evaluation. The literature search was performed

by searching Medline for anal fissure and fissure
for 1980 to 2003.

TREATMENT RECOMMENDATIONS
1. Conservative therapy is safe, has few
side effects, and should usually be the first
step in therapy. Level of evidence: Class II;
Grade of recommendation: B.
Increased fluid and fiber ingestion, the use of sitz
baths, and if necessary, the use of stool softeners such
as docusate sodium or docusate calcium are very
safe,1,2 have virtually no side effects, often diminish
bleeding and pain, and should be instituted as a first
step in virtually all patients with a fissure. These measures result in healing of up to 50 percent of symptomatic fissures, more than in untreated patients.2
Adjunctive measures such as topical anesthetics
cause no harm or decrease in healing rate, and may
be used for patient comfort.3

Dis Colon Rectum, December 2004

2. Anal fissures may be appropriately

treated with topical nitrates because they
can relieve pain; however, nitrates are only
marginally associated with a healing rate
superior to placebo. Level of evidence:
Class I; Grade of recommendation: A.
Topical nitric oxide donors have been associated
with healing in at least 50 percent of chronic fissures
treated410; a rate better than placebo in some studies.6,10 However, the comprehensive Cochrane review of medical treatment of anal fissures concluded
that nitroglycerin was only marginally better than placebo in healing chronic anal fissures.11 Dose escalation12 or use of a transdermal patch13 has not been
shown to improve the healing rate. Use of topical
nitroglycerin significantly decreases pain during the
therapy period.4,6,14 The principal side effect is headache, which is dose-related. The reported incidence
varies but is at least 20 to 30 percent1517 and causes
up to 20 percent of patients to discontinue therapy.13,16
The incidence of fissure recurrence after nitric oxide
donor therapy is dramatically higher4,5 than after surgical therapy; however, the morbidity is lower.5,7,9
Many patients fail therapy because of inability to
maintain the course of therapy with the need for repeated applications.5 Patients who do not respond to
topical therapy should be referred for surgical treatment.4,5,7

3. Anal fissures may be appropriately

treated with topical calcium channel
blockers, which seem to have a lower
incidence of adverse effects than nitrates.
There is insufficient data to conclude
whether they are superior to placebo in
healing fissures. Level of evidence: Class I;
Grade of recommendation: A.
Topical calcium channel blockers have been associated with healing in 65 to 95 percent of chronic
fissures.1821 Topical calcium channel blockers seem
to promote healing by reducing resting anal canal
pressures.19,22 The principal side effects are headache, seen in up to 25 percent of patients,19 flushing,
and less commonly symptomatic hypotension. Orally
administered calcium channel blockers are associated
with a lower rate of fissure healing than topical application and have a higher incidence of side effects.21
There are fewer randomized, controlled trials of topi-

Vol. 47, No. 12

PRACTICE PARAMETERS

cal calcium channel blockers than of topical nitric oxide donors. Few direct comparisons of topical agents
are available.

4. Botulinum toxin injections may be used

for anal fissures that fail to respond to
conservative measures and have been
associated with a healing rate superior to
placebo. There is inadequate consensus on
dosage, precise site of administration,
number of injections or efficacy. Level of
evidence: Class II; Grade of
recommendation: B.
Injection of botulinum toxin into the internal
sphincter produces a temporary chemical sphincterotomy, allowing healing of 60 to 80 percent of fissures after a single injection,16,23,24 at a rate higher
than placebo.25 Botulinum toxin temporarily decreases mean anal canal resting pressures,26,27 an effect that persists for two to three months.28 Some authors also report a transient decrease in mean squeeze
pressure, usually at higher doses.28 Healing takes
longer than after surgical sphincterotomy, but return
to full activity occurs sooner.24 The most common
side effects are transient incontinence of flatus in up
to 10 percent of patients,25,29,30 and stool in approximately 5 percent of cases.28 Recurrences are common
but may be retreated with a good rate of healing.29,30
Topical nitrates seem to potentiate the effect of botulinum toxin in the treatment of patients with a refractory fissure.31 There is no consensus on dose, site, or
number of injections.26,27,32 Higher doses are associated with improved rates of healing and seem to be as
safe as lower doses.29 Up to 20 percent of patients fail
botulinum toxin therapy and go on to surgical sphincterotomy23,26,33; this seems lower if higher doses of
toxin are used.28 There are few randomized, controlled studies, and most reports in the literature contain small numbers, making conclusions about efficacy difficult.

5. Lateral internal sphincterotomy is the

surgical treatment of choice for refractory
anal fissures. Level of evidence: Class I;
Grade of recommendation: A.
Lateral internal sphincterotomy (LIS) should be
considered the treatment of choice for the surgical
management of refractory anal fissures.17,3436 The

2005

use of anal dilation with conservative treatment does

not decrease the likelihood of surgery.37 Forceful anal
dilation is inferior to LIS38,39 owing to a higher recurrence rate35 with higher rates of incontinence.3436
LIS is superior to fissurectomy and posterior midline sphincterotomy owing to faster healing rates, less
pain, and less postoperative incontinence.36,40 The
Cochrane review of surgical treatment of anal fissures
concluded that LIS was superior to anal dilation and
posterior midline sphincterotomy.41

6. Open and closed techniques for LIS

seem to yield similar results. Level of
evidence: Class I; Grade of
recommendation: A.
There does not seem to be any significant difference in outcomes between the open and closed techniques.34,4143

7. Anal advancement flap is an alternative

to LIS; further study is required. Level of
evidence: Class II; Grade of
recommendation: D.
It seems that advancement flap surgery is an acceptable alternative to LIS,44 but there is a lack of
prospective, randomized studies in the literature. This
technique may be particularly attractive in patients
without sphincter hypertonia. Further study with
long-term follow-up is needed.

8. Surgery may be appropriately offered

without a trial of pharmacologic treatment
after failure of conservative therapy; patient
should be informed about the potential
complications of surgery. Level of evidence:
Class I; Grade of recommendation: A.
Topical treatments have problems with compliance,5
a lower rate of healing,5,7,9,24 and a higher recurrence
rate7,9,24 than surgical treatment. As such, a strong case
can be made for surgery without a preliminary trial of
pharmacologic manipulation, although surgery clearly
carries a risk of minor fecal incontinence. Surgery also is
indicated for failed topical therapy.5,7 Incontinence rates
in the literature for LIS vary, but prospective studies
have shown an acceptable level of complications and
LIS is appropriately used in place of topical therapy if
stool softeners and bulking agents fail.17,34,39,4449 Incontinence sufficient to cause any measurable impairment in quality of life seems to be uncommon.50

ORSAY ET AL

2006

Dis Colon Rectum, December 2004

The practice parameters set forth in this document have been developed from sources believed to be reliable. The
American Society of Colon and Rectal Surgeons makes no warranty, guaranty, or representation whatsoever as
to the absolute validity or sufficiency of any parameter included in this document, and the Society assumes no
responsibility for the use or misuse of the material contained.

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PRACTICE PARAMETERS

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